LIAISON

CASE PRESENTATION
5
NAJIAH JANJAN (2013489586)
Patients initial Mrs. L
MRN (Ward 9C)
Age 47 years old
Sex Female
Ethnic group Indian
Marital status Married
Occupation and current employment Unemployed
status
Current address Setapak
Language spoken BM, BI
History taken from Patient and case notes
Date of admission 9 October 2017
Date of clerking 11 October 2017
Chief Complaint
Madam L, a 47 years old, Indian lady, unemployed for 23 years,
widow and alcoholic was referred from ward 9C for alcohol withdrawal
on day 2 of admission.
 History of Presenting Illness

She was admitted to Selayang Hospital for community acquired

pneumonia.
She had fever, cough and shortness of breath for 3 days but worsening
on the day of admission.
It was productive cough with whitish sputum. It was associated with
pleuritic chest pain and palpitation.
Fever associated with chills but no rigor, not taking PCM.
Otherwise, no nausea and vomitting, no abdominal pain, no diarrhea
and no UTI symptoms.
 Upon further questioning, her last drank alcohol on Saturday night
(7/10/17).
She took one bottle of Orang Tua 500ml with 17% alcohol
percentage, drank it raw, did not mix it with anything else.
After that,patient started to have cough and difficulty in breathing.
Hence, was brought to ED Selayang Hospital.
 Upon further history, patient used to drink occasionally usually during
weddings or festivities.
However, since August this year, she has been drinking daily.
Initially was one bottle, then started to drink 3 bottles->5 bottles
She can drinks up to maximum of 10 bottles per day.
She will wait outside Liquor store in Selayang Prima for store to open.
Sometime sleeps outside shop. She will wake up and go to adopted
brother's house for food or will buy food outsid.
She drink to forget her life and feeling bored.
She expressed that she actually wants to drink so much that shecould
just die.
 Feels lonely since the death of her husband in 2013 and wishes she
could find a companion.
She claimed had been having low mood since 2013.
She felt upset that she is alone, and unable to live by herself.
Patient has made 2 suicidal attempts in the past. Both attempts were
stopped by her very close male friend,whom she referred to as an
adopted brother.
Both occured in 2013, after her husband's death.
1st attempt, she wanted to introduce a syringue with air into her veins.
2nd attempt,she wanted to cut her wrists.
 She admitted that she did that to get the attention of her adopted
brother so she could see how much he cares.
She has suicidal wish. However, does not made any plan ( no more
attempt since 2013, no suicidal note)
She has been having difficulty in sleeping since August, she wakes up
frequently at night.
Otherwise, no loss of appetite, no feeling of hopelessness or
worthlessness, no anhedonia, no hallucinations and no delusions.
PAST PSYCHIATRIC
There was no past psychiatric history

PAST MEDICAL/SURGICAL HISTORY

Newly diagnosed with hypertension in Aug at KK Sg. Tua. She was not
on medication and had no proper follow up.
Bronchial asthma diagnosed at age of 11. Not on medication. Her last
attack at age of 13, admitted in HKL.

ALLERGY HISTORY
Allergic to penicilin.
FAMILY HISTORY
Her father passed away many years ago. Her mother is alive and well.
Staying with her younger sister in Setapak.
She is 2nd out of 5 siblings.

She says that she has 3 adopted brothers. These brothers are her
close friends that she know since 2004.
They lived in same area, Selayang Prima.
She was treated like a sister by them.
Personal History
Birth history
Patient was unsure about pregnancy and birth.

Childhood history
Developmental milestones were normal
No physical and emotional abuse
Education history

She studied till SPM but unsure the result.

She claimed to had a lot of friends back in the school
She had disciplinary problems such as truancy, but no bullying.
Occupational history :

Started to work in KFC, after completing SPM.

From 1967-1994, she was working as receptionist for Yao Han Plaza.
She stopped working after that.
Sexual & marital history :
She had 2 marriages.
1st marriage was from 1995-2000. It was love marriage.
Courted for few months prior to marriage. Had one miscarriage.
Blessed with one child in 1996. Child passed away when she was 10
years old.
Her daughter was a victim of a road traffic accident, hit by a car while
crossing the road)
Patient has difficulty conceiving but never investigated.
She did not know her 1st husband was a drug addict prior to
marriage. Husband passed away in the year 2000 as he overdosed on
Heroin.
 Patient was actively taking Heroin and smoking when she was pregnant.
She did not know she was pregnant.
When to bathroom cause of stomach pain, when baby's head
spontaneously came out from vulva.
Baby was delivered prematurely at 7 months, at home. Then, treated for
withdrawal syndrome.
The child was then raised by patient's aunt since birth up to her demise.
2nd marriage
Married from 2004-2013
Met via friends.
Courted for one year prior to a marriage. It was love marriage, and
had no children.
Husband passed away due to Hypertensive Emergency->stroke-
>coma
Substance history :
1. Alcohol
as mentioned before
2. Heroin
start chasing heroin in 1995
husband takes it daily, she then felt curious
so, she started smoking also. She enjoys the high feeling
RM 50 shared between them. Then, due to financial restraint,
patient and her husband started to use IV Heroin.
Caught by the police twice and sent to Pusat Serenti ( last was in
2003)
3. Cigarette

started taking at 17 years of age

At that time, shared a pack between 6-7 girls.
Now, smokes 6-7 stick per day
Social condition :
Stay in the house of her 2nd husband owned, willed it to her.
She has then transferred the property to one of the adopted brothers.
The house is a double storey terrace house with 3 rooms. 2 rooms are
rented out to other people.
One room is given to patient.
Rent money goes to adopted brother as he take cares of the
maintenance of the house.
She gets pocket money from the adopted brother.

Forensic history : As mentioned

Pre - morbid personality
She is a friendly person.
Extrovert person and very independent, not depend to the family.
She made her own decision and face the consequences by herself.
She said that her father always called her as stubborn girl.
 Mental state examination
General Appearance & behaviour
Comfortable looking middle aged Indian lady, wearing a hospital attire with small
body built.
Hair unkempt hair,but good hygiene
Normal eye contact
Behavior to interviewer = good rapport but became hostile when asking about
family, substance use
Speech
Spontaneous
Normal tone
Normal rate and volume
Relevant
Coherent
No loose of association
Mood
Euthymic. She said OK.
Affect
Affect is appropriate and mood congruent.Became irritated and teary eye
when talking about family.

Perceptual Disturbances
No hallucination or illusion.

Thought Disturbances
Content: Suicidal wish
No delusion
No obsessional thought
No flight of ideas
No suicidal ideation
 COGNITIVE FUNCTION
Orientation
She oriented to time, place and person.

Memory
Immediate recall: able to recall kacang, bola,batu
Short term : able to recall
Long term : able to recall her birthdate

Attention and Concentration

Unable to do serial 7-s since patient refused

Intelligence and General Knowledge

She knew the current and the first prime minister.
She was able to answer the date of country independence
Abstraction
Able to interpret harapkan pagar, pagar makan padi as kawan makan
kawan
The similarity between apple and orange as round shape. Car and
motorboat as both have engine

Judgment
Good judgment when asked about what she will do if there is fire in
the building call firefighter

Insight
She knew that she had alcohol addiction and having emotion problem
since her husband demise. She said she had to drink because she felt
lonely.
She accept her current condition and not keen to seek a treatment.
General Examination
She was sitting comfortably with mild hand tremors,jittery, tachypnea and not in pain.
On nasal prong 3L
She had moderate hydrational status
No conjunctiva pallor/jaundice

Vital signs
Blood pressure : 132/86 mmHg
Pulse rate : 102 beat per minute, good volume and rhythm
Respiratory rate : 21 breaths per minute
Temperature : 36.7oC
Systemic Examination
SYSTEM COMMENT

CARDIOVASCULAR S1 S2 heart sound heard. There was no murmur

RESPIRATORY Prolonged exp. phase bilateral lower zone coarse crepitation

with rhonchi.

ABDOMINAL SYSTEM Soft, Non-tender

There was no organomegaly or mass palpable.
Bowel sound was heard.

CENTRAL NERVOUS SYSTEM Normal power and reflexes with no significant abnormalities
detected.
SUMMARY
Madam L, a 47 years old, Indian lady, unemployed for 23 years, widow
and alcoholic was referred from ward 9C for alcohol withdrawal on day 2 of
admission. She drank Orang Tua 500ml with 17% alcohol everyday, can
drinks up to 10 bottles per day. She had depressed mood and suicidal wish
since 2013 due to demise of her 2nd husband with 2 suicidal attempts.
Otherwise, no loss of appetite, no feeling of hopelessness or
worthlessness, no anhedonia, no hallucinations and no delusions.
On examination, patient had mild tremor and jittery and tacypneic. MSE
day 3, patient currently euthymic with appropriate affect.She had suicidal
wish and poor insight.